Background Children <8 years who were prematurely transitioned from a booster seat to a seat belt (booster transition) have a higher road traffic injury risk. This qualitative research aimed to explore the parent’s decision-making on booster transition and to identify factors that influence parents’ decisions. Methods We conducted 20 semi-structured interviews virtually with parents/guardians from Columbus, Ohio. All individual interviews were audio-recorded and transcribed verbatim. Grounded theory with initial coding and focused coding was used to analyze data. All transcribed data were imported into NVivo and coded by two researchers followed by group discussions to identify themes and resolve discrepancies. Results We identified eight themes that were related to parents’ decision-making on booster transition. Internet was the most common source for parents seeking information regarding booster seats. Many participants reported the information they found was useful and trustworthy, though some participants talked about the challenges of finding accurate information and deciphering information regarding when they should stop using booster seats. Conclusion Our findings have important implications for developing interventions to improve booster seat use, highlighting the necessity of redesigning educational materials regarding the proper booster transition. Learning outcomes Eight themes associated with booster transition were identified. Three of them are child-related: (1) age and physical size; (2) maturity; and (3) motivation and willingness. The remaining five are parent-related: (1) safety as a priority; (2) convenience of non-use; (3) awareness and knowledge about the law; (4) influence from others (spouse, pediatricians, et al.,); (5) decision-making approaches.

Objective While prior studies have found parental socioeconomic status (SES) affects the outcomes of pediatric traumatic brain injury (TBI), the longitudinal trajectory of this effect is not well understood. Methods This prospective cohort study included children 8-18 years of age admitted to six sites with a complicated mild (n = 123) or moderate-severe TBI (n = 47). We used caregiver education and household poverty level as predictors, and multiple quality of life and health behavior domains as outcomes. Differences at 6, 12, and 24 months from baseline ratings of pre-injury functioning were compared by SES. We examined the association between measures of SES and domains of functioning over the 24 months post-injury in children with a complicated mild or moderate- severe TBI, and determined how this association varied over time. Results Parental education was associated with recovery among children with complicated mild TBI; outcomes at 6, 12, and 24 months were substantially poorer than at baseline for children with the least educated parents. After moderate-severe TBI, children in households with lower incomes had poorer outcomes compared to baseline across time. Implications Parental education and household income were associated with recovery trajectories for children with TBI of varying severity.

Objective The aims of this study were to evaluate trends over time in computed tomography (CT) scan utilization after implementation of a clinical pathway in a tertiary care children's hospital emergency department (ED), to determine how ED throughput differs by CT utilization, and to determine provider reasoning for obtaining head CT in low-risk patients. Methods This was a retrospective cohort study of patients 21 years or younger discharged from our ED with head trauma (Glasgow Coma Scale score ≥13 and a head trauma International Classification of Diseases code) over a 5-year period, starting 1 year after pathway implementation (January 2012 to December 2016). A manual chart review of 10% of patients who received a CT was performed to determine reasoning for CT utilization and guideline compliance. Results In total, 6.3% (95% confidence interval [CI], 5.9%–6.6%) of 21,129 discharged patients received a head CT, decreasing annually by an average of 0.9%. Pediatricians were more likely to obtain a CT than pediatric emergency medicine physicians after adjusting for acuity (odds ratio, 1.37; 95% CI, 1.02–1.82). Those who received a CT stayed 90 minutes longer (95% CI, 79–101 minutes) than those who did not after propensity score matching. Thirty percent of patients who received a CT in our manual chart review met low-risk Pediatric Emergency Care Applied Research Network criteria. Conclusions Head CT rates in patients with minor head trauma consistently decreased each year after guideline implementation. Children who received head CT did not have prolonged lengths of stay compared with those who did not. A minority of patients who received a CT and were discharged met low-risk criteria by standardized guidelines.

Objective: To validate an electronic health record (EHR)-based algorithm to classify ADHD status of pediatric patients. Method: As part of an applied study, we identified all primary care patients of The Children's Hospital of Philadelphia [CHOP] health care network who were born 1987-1995 and residents of New Jersey. Patients were classified with ADHD if their EHR indicated an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code of "314.x" at a clinical visit or on a list of known conditions. We manually reviewed EHRs for ADHD patients (n = 2,030) and a random weighted sample of non-ADHD patients (n = 807 of 13,579) to confirm the presence or absence of ADHD. Results: Depending on assumptions for inconclusive cases, sensitivity ranged from 0.96 to 0.97 (95% confidence interval [CI] = [0.95, 0.97]), specificity from 0.98 to 0.99 [0.97, 0.99], and positive predictive value from 0.83 to 0.98 [0.81, 0.99]. Conclusion: EHR-based diagnostic codes can accurately classify ADHD status among pediatric patients and can be used by large-scale epidemiologic and clinical studies with high sensitivity and specificity.

Purpose: The purpose of this study was to evaluate the internal consistency and construct validity of the Traumatic Brain Injury Quality of Life Communication Item Bank (TBI-QOL COM) short form as a parent-proxy report measure. The TBI-QOL COM is a patient-reported outcome measure of functional communication originally developed as a self-report measure for adults with traumatic brain injury (TBI), but it may also be valid as a parent-proxy report measure for children who have sustained TBI.Method: One hundred twenty-nine parent-proxy raters completed the TBI-QOL COM short form 6 months postinjury as a secondary aim of a multisite study of pediatric TBI outcomes. The respondents’ children with TBI were between 8 and 18 years old (Mage = 13.2 years old) at the time of injury, and the proportion of TBI severity mirrored national trends (73% complicated–mild; 27% moderate or severe).Results: The parent-proxy report version of the TBI-QOL COM displayed strong internal consistency (ordinal α = .93). It also displayed evidence of known-groups validity by virtue of more severe injuries associated with more abnormal scores. The instrument also showed evidence of convergent and discriminant validity by displaying a pattern of correlations with other constructs according to their conceptual relatedness to functional communication.Conclusions: This preliminary psychometric investigation of the TBI-QOL COM supports the further development of a parent report version of the instrument. Future development of the TBI-QOL COM with this population may include expanding the content of the item bank and developing calibrations specifically for parent-proxy raters.Supplemental Material S1. Comparison of completers vs. noncompleters at 6 months. Cohen, M. L., Tulsky, D. S., Boulton, A. J., Kisala, P. A., Kertisch, H., Yeates, K. O., . . . Rivara, F. P. (2019). Reliability and construct validity of the TBI-QOL Communication short form as a parent-proxy report instrument for children with traumatic brain injury. Journal of Speech, Language, and Hearing Research. Advance online publication. https://doi.org/10.1044/2018_JSLHR-L-18-0074

Purpose The purpose of this study was to evaluate the internal consistency and construct validity of the Traumatic Brain Injury Quality of Life Communication Item Bank (TBI-QOL COM) short form as a parent-proxy report measure. The TBI-QOL COM is a patient-reported outcome measure of functional communication originally developed as a self-report measure for adults with traumatic brain injury (TBI), but it may also be valid as a parent-proxy report measure for children who have sustained TBI. Method One hundred twenty-nine parent-proxy raters completed the TBI-QOL COM short form 6 months postinjury as a secondary aim of a multisite study of pediatric TBI outcomes. The respondents' children with TBI were between 8 and 18 years old ( M age = 13.2 years old) at the time of injury, and the proportion of TBI severity mirrored national trends (73% complicated-mild; 27% moderate or severe). Results The parent-proxy report version of the TBI-QOL COM displayed strong internal consistency (ordinal α = .93). It also displayed evidence of known-groups validity by virtue of more severe injuries associated with more abnormal scores. The instrument also showed evidence of convergent and discriminant validity by displaying a pattern of correlations with other constructs according to their conceptual relatedness to functional communication. Conclusions This preliminary psychometric investigation of the TBI-QOL COM supports the further development of a parent report version of the instrument. Future development of the TBI-QOL COM with this population may include expanding the content of the item bank and developing calibrations specifically for parent-proxy raters. Supplemental Material https://doi.org/10.23641/asha.7616534.

Introduction: Neonates may require increased red cell mass to optimise oxygen content after stage 1 palliation; however, data informing transfusion practices are limited. We hypothesise there is a patient-, provider-, and institution-based heterogeneity in red cell transfusion decision-making after stage 1 palliation. Methods: We conducted an online survey of Pediatric Cardiac Intensive Care Society practitioners in 2016. Respondents answered scenario-based questions that defined transfusion indications and identified haematocrit transfusion thresholds. Respondents were divided into restrictive and liberal groups based on a haematocrit score. Fisher's exact test was used to determine the associations between transfusion likelihood and patient, provider, and institutional characteristics. Bonferroni correction was applied to adjust the p-value to 0.004 for multiple comparisons. Results: There was a 21% response rate (116 responses). Most were male (58.6%), attending physicians (85.3%) with >5 year of intensive care experience (88.7%) and subspeciality training in critical care medicine (47.4%). The majority of institutions were academic (96.6%), with a separate cardiac ICU (86.2%), and performed >10 stage 1 palliation cases annually (68.1%). After Bonferroni correction, there were no significant patient, respondent, or institutional differences between the restrictive and liberal groups. No respondent or institutional characteristics influenced transfusion decision-making after stage 1 palliation. Conclusions: Decision-making around red cell transfusion after stage 1 palliation is heterogeneous. We found no clear relationships between patient, respondent, or institutional characteristics and transfusion decision-making among surveyed respondents. Given the lack of existing data informing red cell transfusion after stage 1 palliation, further studies are necessary to inform evidence-based guidelines.

OBJECTIVES: In this study, we describe unmet service needs of children hospitalized for traumatic brain injury (TBI) during the first 2 years after injury and examine associations between child, family, and injury-related characteristics and unmet needs in 6 domains (physical therapy, occupational therapy, speech therapy, mental health services, educational services, and physiatry). METHODS: Prospective cohort study of children age 8 to 18 years old admitted to 6 hospitals with complicated mild or moderate to severe TBI. Service need was based on dysfunction identified via parent-report compared with retrospective baseline at 6, 12, and 24 months. Needs were considered unmet if the child had no therapy services in the previous 4 weeks, no physiatry services since the previous assessment, or no educational services since injury. Analyses were used to compare met and unmet needs for each domain and time point. Generalized multinomial logit models with robust SEs were used to assess factors associated with change in need from pre-injury baseline to each study time point. RESULTS: Unmet need varied by injury severity, time since injury, and service domain. Unmet need was highest for physiatry, educational services, and speech therapy. Among children with service needs, increased time after TBI and complicated mild TBI were associated with a higher likelihood of unmet rather than met service needs. CONCLUSIONS: Children hospitalized for TBI have persistent dysfunction with unmet needs across multiple domains. After initial hospitalization, children with TBI should be monitored for functional impairments to improve identification and fulfillment of service needs.

Purpose: We examined the frequency of adolescents' and their parents' mobile phone use while driving (MPUWD) in the context of their peer and parent-child interlocutors (i.e., communication partners), considering individual differences in perceived risk and symptoms of technology addiction.Methods: Ninety-four participants (47 parent-adolescent dyads) completed a survey battery measuring their symptoms of technology addiction, perceived risk of MPUWD, and MPUWD with family members and with their peers as assessed via the proportion of trips when drivers used a mobile phone to communicate.Results: For both adolescents and their parents across both types of interlocutors (parent-child, peer), stronger risk perceptions were associated with less MPUWD, and stronger symptoms of technology addiction were associated with more MPUWD. A three-way interaction among technology addiction, interlocutor (parent-child, peer), and driver (parent, adolescent) was observed. For adolescents, the association between technology addiction and MPUWD was significantly stronger for MPUWD with their peers than it was for their MPUWD with their parents; this association was not observed for parents. Parents engaged in MPUWD with their children as frequently as adolescents engaged in MPUWD with their peers.Conclusions: Symptoms of technology addiction play a stronger role for adolescents' MPUWD with their peers than it does for adolescents' MPUWD with their parents. These and other driver-by-interlocutor interactions should be considered in future research on distracted driving and in prevention efforts.

Objectives: Child Restraint System (CRS) misuse is common. We characterized caregivers’ use of child passenger safety informational and instructional resources and determined whether there were differences in the quality of CRS installations associated with prior exposure to specific resources as evaluated in a standardized CRS installation environment. Methods: Caregivers completed self-report surveys and installed a forward-facing CRS in a controlled environment. Installations were evaluated for security (tightness) and accuracy (no errors) by a child passenger safety technician (CPST). Results: CRS manuals were the most common way caregivers learned to install a CRS. Primary care providers (PCP)s were the most frequently endorsed source of CRS safety information. There was no strong pattern of associations between prior exposure to resources and installation quality (security or accuracy), although some evidence supports protective effects of learning from CPSTs; 13% (19 out of 151) installations were secure and 57% (86 out of 151) installations were accurate. Conclusions: A focus on developing effective and lasting behavioral interventions is needed.

The primary objective is to provide evidence of convergent and discriminant validity for the pediatric and parent-proxy versions of the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety, Depression, Anger, Peer Relations, Mobility, Pain Interference, and Fatigue item banks, the Neurology Quality of Life measurement system (Neuro-QOL) Cognition-General Concerns and Stigma item banks, and the Traumatic Brain Injury Quality of Life (TBI-QOL) Executive Function and Headache item banks in a pediatric traumatic brain injury (TBI) sample.

bjective: Newly licensed adolescent drivers have skill deficits that increase risk for motor vehicle crashes. Development of programs targeted to prelicensed adolescents has been hindered by concerns about encouraging overconfidence and early licensure. The study had 2 primary objectives: (a) determine whether an Internet-based intervention designed to improve parent-supervised practice (TeenDrivingPlan [TDP]) influenced adolescents' time to licensure and parents' perceptions of adolescents' driving skill, expertise, and safety and (b) evaluate the association of these perceptions and practice diversity (number of different environments where practiced occurred) with time to licensure. Method: A randomized controlled trial was used to compare TDP with a control condition. Participants (N = 295 parentadolescent dyads) completed periodic surveys over 24 weeks and were subsequently followed for up to a year to determine adolescents' licensure status. Results: TDP did not influence time to licensure and did not affect parents' perceptions of skill, expertise, and safety. Practice diversity was associated with faster licensure. A more favorable perception of adolescents' skill in comparison to peers was associated with faster licensure. Conclusions: Targeting parents' beliefs about adolescents' safety in relation to other road users may not be conducive to altering licensing trajectories, whereas sensitizing parents to their adolescents' emerging skills might be more effective in promoting safe entry into licensure.

Objectives: Current information on the safety of rear row occupants of all ages is needed to inform further advances in rear seat restraint system design and testing. The objectives of this study were to describe characteristics of occupants in the front and rear rows of model year 2000 and newer vehicles involved in crashes and determine the risk of serious injury for restrained crash-involved rear row occupants and the relative risk of fatal injury for restrained rear row vs. front passenger seat occupants by age group, impact direction, and vehicle model year.Method: Data from the National Automotive Sampling System Crashworthiness Data System (NASS-CDS) and Fatality Analysis Reporting System (FARS) were queried for all crashes during 2007-2012 involving model year 2000 and newer passenger vehicles. Data from NASS-CDS were used to describe characteristics of occupants in the front and rear rows and to determine the risk of serious injury (AIS 3+) for restrained rear row occupants by occupant age, vehicle model year, and impact direction. Using a combined data set containing data on fatalities from FARS and estimates of the total population of occupants in crashes from NASS-CDS, logistic regression modeling was used to compute the relative risk (RR) of death for restrained occupants in the rear vs. front passenger seat by occupant age, impact direction, and vehicle model year.Results: Among all vehicle occupants in tow-away crashes during 2007-2012,12.3% were in the rear row where the overall risk of serious injury was 1.3%. Among restrained rear row occupants, the risk of serious injury varied by occupant age, with older adults at the highest risk of serious injury (2.9%); by impact direction, with rollover crashes associated with the highest risk (1.5%); and by vehicle model year, with model year 2007 and newer vehicles having the lowest risk of serious injury (0.3%). Relative risk of death was lower for restrained children up to age 8 in the rear compared with passengers in the right front seat (RR= 0.27, 95% Cl 0.12-0.58 for 0-3 years, RR= 0.55, 95% CI 0.30-0.98 for 4-8 years) but was higher for restrained 9-12-year-old children (RR= 1.83, 95% CI 1.18-2.84). There was no evidence for a difference in risk of death in the rear vs. front seat for occupants ages 13-54, but there was some evidence for an increased relative risk of death for adults age 55 and older in the rear vs. passengers in the right front seat (RR= 1.41, 95% Cl 0.94-2.13), though we could not exclude the possibility of no difference. After controlling for occupant age and gender, the relative risk of death for restrained rear row occupants was significantly higher than that of front seat occupants in model year 2007 and newer vehicles and significantly higher in rear and right side impact crashes.Conclusions: Results of this study extend prior research on the relative safety of the rear seat compared with the front by examining a more contemporary fleet of vehicles. The rear row is primarily occupied by children and adolescents, but the variable relative risk of death in the rear compared with the front seat for occupants of different age groups highlights the challenges in providing optimal protection to a wide range of rear seat occupants. Findings of an elevated risk of death for rear row occupants, as compared with front row passengers, in the newest model year vehicles provides further evidence that rear seat safety is not keeping pace with advances in the front seat. (C) 2015 Elsevier Ltd. All rights reserved.

Objective To evaluate the validity of a parent-reported survey to identify children's moderate and serious injuries in seven specific body regions using medical records as the gold standard'.Methods A prospective validation study was conducted in three urban paediatric emergency departments (EDs). 798 parents of 859 children treated for injuries at participating EDs between August 2010 and July 2011 completed either a telephone interview or self-administered paper survey at 2weeks post-ED visit. Parents were asked to report child injuries to seven body regions: head, face, neck/spine/back, thorax, abdomen, upper extremities and lower extremities. Injury data were abstracted from medical records using a standardised protocol. Body region injury severity levels of none/minor, moderate or serious were assigned to each subject based on the Abbreviated Injury Scale.Results The overall sensitivity, reflecting parents' ability to identify a documented moderate or greater severity injury, was 0.95 (95% CI 0.92 to 0.97). Sensitivities were >0.90 for the face, upper extremity and lower extremity regions; 0.80-0.90 for head, abdomen and neck/back/spine regions; and <0.60 for the thorax region. The overall sensitivity for identification of a serious injury was 0.71 (0.60 to 0.80).Conclusions This survey enables parents to accurately identify moderate and greater severity injuries to body regions, though it does not accurately identify serious injuries in most body regions except the extremities. The survey could serve as a screening tool to identify moderate and greater severity injuries in population-based surveillance systems, or as the primary outcome of interest in injury prevention studies.

Background: Few studies have concurrently assessed the influence of age and experience on young driver crashes, in particular in the post-Graduated Driver Licensing (GDL) era. Further, little attention is given to the transition from intermediate to full licensure. We examined the independent and joint contributions of licensing age, driving experience, and GDL license phase on crash rates among the population of young New Jersey (NJ) drivers.Methods: From a unique linked database containing licensing and crash data, we selected all drivers who obtained their NJ intermediate license at 17-20 years old from 2006-2009 (n=410,230). We determined the exact age at which each driver obtained an intermediate and full license and created distinct, fixed cohorts of drivers based on their age at intermediate licensure. For each cohort, we calculated and graphed observed monthly crash rates over the first 24 months of licensure. Further, we examined crash rates by age at licensure, driving experience (i.e., time since licensure), and license phase.Results: First-month crash rates were higher among the youngest drivers (licensed at 17y0m). Drivers who were licensed later experienced a reduced "steepness" in the slope of their crash rates in the critical initial months of driving, but there did not appear to be any incremental benefit of later licensure once drivers had six months of driving experience. Further, at each age, those with more driving experience had lower crash rates; however, the benefit of increased experience was greatest for the substantial proportion of teens licensed immediately after becoming eligible (at 17y0m). Finally, independent of age and experience, teen drivers' crash risk increased substantially at the point of transition to a full license, while drivers of a similar age who remained in the intermediate phase continued to experience a decline in crash rates.Conclusion: Age and driving experience interact to influence crash rates. Further, independent of these two factors, there is an abrupt increase in crash risk at the point of transition from intermediate to full licensure. Future studies should investigate whether this increase is accounted for by a change in driving exposure, driving behaviors, and/or other factors. (C) 2015 Elsevier Ltd. All rights reserved.

BACKGROUND:Police crash reports have been used to advance motor vehicle safety research, though their value is limited by their focus on the crash event rather than outcomes of the crash.OBJECTIVE:To develop and evaluate the effect of enhanced recruitment methods, including a monetary incentive, on response rates of drivers identified on police reports in a national MVC surveillance system.METHODS:The National Automotive Sampling System-General Estimates System (NASS-GES) was used to identify passenger vehicle crashes between 1 July and 30 October 2012 involving drivers ≥16 years old with at least one child occupant ≤17 years old. We collected data from the driver via self-administered hardcopy or interviewer-administered telephone surveys. Within each survey mode, half the drivers were randomly assigned to receive a small monetary incentive. Response rates were calculated overall, and by mode of survey administration and incentive condition.RESULTS:495 drivers were eligible, and 127 completed the survey, yielding an overall response rate of 25.7% (95% CI 21.8% to 29.5%). The response rate across the two modes was higher for those who received an incentive than for those who did not (35.6% vs 15.7%, p<0.01). The highest response rate (45.9%) was for drivers allocated to the telephone survey who received an incentive.CONCLUSIONS:The NASS-GES provides a surveillance system from which cases of interest can be identified and supplemental data collected via surveys of drivers identified on police reports. We adapted procedures commonly used in public health surveillance systems, including monetary incentives and branded recruitment materials, to improve driver response rates.

Objective: Injury is a leading cause of emergency department visits, disability, and death in children. This study examined the sensitivity and specificity of parental report of children’s specific injuries. Methods: A prospective validation study was conducted in 3 urban pediatric emergency departments from August 2010 to July 2011. Parents of injured children completed a survey at 2-weeks following the emergency department visit, and their responses were compared to injury data that were abstracted from medical records. Results: Parent surveys were completed for 516 injured children. Sensitivities were ≥0.75 for all fractures and ≥0.88 for extremity and skull fractures. Internal organ injuries were generally less accurately reported by parents than fractures. Specificity estimates all exceeded 0.95. Conclusions: This telephone-administered and mailed self-administered survey enabled parents to accurately report specific head and extremity injuries. Practical Applications: This survey may be a useful tool for pediatric injury surveillance activities.

OBJECTIVE:Inexperienced, less-skilled driving characterises many newly licensed drivers and contributes to high crash rates. A randomised trial of TeenDrivingPlan (TDP), a new learner driver phase internet-based intervention, demonstrated effectiveness in improving safety relevant, on-road driving behaviour, primarily through greater driving practice diversity. To inform future learner driver interventions, this analysis examined TDP use and its association with practice diversity.DESIGN:Posthoc analysis of data from teen/parent dyads (n=107), enrolled early in learner phase and assigned to treatment arm in randomised trial.METHODS:Inserted software beacons captured TDP use data. Electronic surveys completed by parents and teens assessed diversity of practice driving and TDP usability ratings at 24 weeks (end of study period).RESULTS:Most families (84%) used TDP early in the learner period; however, the number of TDP sessions in the first week was three times higher among dyads who achieved greater practice diversity than those with less. By week five many families still engaged with TDP, but differences in TDP use could not be detected between families with high versus low practice diversity. Usability was not a major issue for this sample based on largely positive user ratings.CONCLUSIONS:An engaging internet-based intervention, such as TDP, can support families in achieving high practice diversity. Future learner driver interventions should provide important information early in the learner period when engagement is greatest, encourage continued learning as part of logging practice drives, and incorporate monitoring software for further personalisation to meet family needs.TRIAL REGISTRATION:NCT01498575.

Recent surveys have provided insight on the primary reasons why US teens delay licensure but are limited in their ability to estimate licensing rates and trends. State administrative licensing data are the ideal source to provide this information but have not yet been analyzed for this purpose. Our objective was to analyze New Jersey's (NJ) licensing database to: (1) describe population-based rates of licensure among 17- to 20-year-olds, overall and by gender and zip code level indicators of household income, population density, and race/ethnicity; and (2) examine recent trends in licensure. We obtained records on all licensed NJ drivers through June 2012 from the NJ Motor Vehicle Commission's licensing database and determined each young driver's age at the time of intermediate and full licensure. Data from the US Census and American Community Survey were used to estimate a fixed cohort of NJ residents who turned 17 years old in 2006-2007 (n=255,833). Licensing data were used to estimate the number of these drivers who obtained an intermediate license by each month of age (numerators) and, among those who obtained an intermediate license, time to graduation to full licensure. Overall, 40% of NJ residents-and half of those who ultimately obtained a license by age 21-were licensed within a month of NJ's minimum licensing age of 17, 64% by their 18th birthday, and 81% by their 21st birthday. Starkly different patterns of licensure were observed by socioeconomic indicators; for example, 65% of 17-year-olds residing in the highest-income zip codes were licensed in the first month of eligibility compared with 13% of residents living in the lowest-income zip codes. The younger an individual obtained their intermediate license, the earlier they graduated to a full license. Finally, the rate and timing of licensure in NJ has been relatively stable from 2006 to 2012, with at most a 1-3% point decline in rates. These findings support the growing body of literature suggesting that teens delay licensure primarily for economic reasons and that a substantial proportion of potentially high-risk teens may be obtaining licenses outside the auspices of a graduated driver licensing system. Finally, our finding of a relatively stable trend in licensure in recent years is in contrast to national-level reports of a substantial decline in licensure rates.