Australian Occupational Therapy Journal (2012) 59, 17–22 doi: 10.1111/j.1440-1630.2011.00966.x

Australian Occupational Therapy Journal

Research Article

Restraint of children with additional needs in motorvehicles: Knowledge and challenges of paediatricoccupational therapists in Victoria, Australia

Anne Baker,1 Jane Galvin,2 Lisa Vale3 and Helen Lindner4

1Murdoch Childrens Research Institute, Parkville, Australia, 2Victorian Paediatric Rehabilitation Service, The RoyalChildren’s Hospital, Melbourne, Australia; Murdoch Childrens Research Institute, Parkville, Australia; Latrobe University,Melbourne, Australia, 3Occupational Therapy Department, The Royal Children’s Hospital, Melbourne, Australia, and4VicRoads, Kew, Victoria, Australia

Aim: This research project aimed to understand the chal-lenges faced by occupational therapists when making rec-ommendations regarding the restraint of children withadditional needs in motor vehicles in Victoria, Australia.Methods: A cross-sectional survey design was used toexplore current practice in relation to the prescription ofmotor vehicle restraints in Victoria, Australia. An elec-tronic survey was sent to occupational therapists workingwith children aged from birth to 18 years in early inter-vention services, hospitals, schools, community services orprivate practice.Results: Challenges faced by occupational therapistsrelated to a lack of knowledge of relevant standards andlegal requirements, issues seating children with behaviouraldifficulties, families’ inability to purchase recommendedequipment and constraints as a result of funding issues.Conclusion: Further work is required to develop appro-priate resources which support occupational therapists tomake car seating recommendations for children with addi-tional needs which comply with Australian legal require-ments and standards.

Anne Baker BOccThy (Hons); Research Assistant. JaneGalvin MOT, BAppSci (OT); Senior Occupational Therapist.Lisa Vale BAppSci (OT); Manager Occupational Therapy.Helen Lindner MPPM, Grad Dip (Admin of child and familyprograms), Dip (Early Childhood); Senior Project Manager -Early Childhood.

Correspondence: Jane Galvin, Victorian Paediatric Rehabili-tation Service, The Royal Children’s Hospital, FlemingtonRoad, Parkville, Melbourne, Vic. 3052, Australia. Email:jane.galvin@rch.org.au

Accepted for publication 25 May 2011.

��C 2011 The AuthorsAustralian Occupational Therapy Journal��C 2011 OccupationalTherapy Australia

KEY WORDS additional needs, car restraint, childrestraint, motor vehicles.

Introduction

The Canadian Model of Occupational Performance high-

lights the reciprocal interaction that exists between a per-

son, their environment and the occupations which they

are able to perform. Occupational performance refers to

‘the ability to choose and satisfactorily perform meaning-

ful occupations that are culturally defined, and appropri-

ate for looking after oneself, enjoying life, and contributing

to the social and economic fabric in a community’ (Law,

Polatajko, Baptise & Townsend, 2002, p. 45). For many

Australian families, the car is the most common form of

transportation and is central to facilitating occupational

performance in childhood. Children need to be able to tra-

vel safely and comfortably in a car to enable them to be

transported to and from school, to and from leisure activi-

ties and to and from medical appointments. This is partic-

ularly true for families of children with additional needs,

where public transport is often not a viable option due to

physical, cognitive or behavioural challenges.

Motor vehicle crashes remain one of the leading causes

of death among infants and children in Australia (Austra-

lian Bureau of Statistics, 2010), and serious injury has

been associated with the use of sub-optimal restraint

options; that is, when the child uses a restraint type that

is not the most size-appropriate or when the restraint is

not being used as it was designed to be used. In a retro-

spective case review investigating the relationship

between restraint usage and injury outcome in children

aged 2–8 years involved in a motor vehicle crash in New

South Wales, Australia (Brown, McCaskill, Henderson &

Bilston, 2006), it was found that a total of 82% of children

were sub-optimally restrained at the time of the crash.

Injury severity between optimally restrained children (i.e.

children who were seated in size-appropriate restraints

and the restraint was being used as it was designed) and

18 A. BAKER ET AL.

sub-optimally restrained children differed significantly,

with children who were sub-optimally restrained receiv-

ing a greater proportion of moderate to severe injuries

than those who were optimally restrained.

VicRoads (2010) is the state and road traffic authority

in Victoria, Australia. As part of the Victorian Transport

Act 1983, VicRoads aims to assist the Australian govern-

ment to achieve a range of transport objectives. This

includes reducing the number and severity of road

crashes in Victoria. In November 2009, VicRoads intro-

duced new road rules about the restraint of children in

motor vehicles in accordance with the child’s age, weight

and height, requiring all children under the age of seven -

years to be seated in a size-appropriate restraint. Car

restraints that have been tested for compliance with the

Australian Standard AS ⁄ NZS 1754 (Child Restraint Sys-tems for use in Motor Vehicles) are commonly referred to as

‘standards-approved restraints’. Although there are clear

guidelines and multiple choices of restraints for typically

developing children, issues can arise when trying to use

these same restraint options with children who have

additional needs such as orthopaedic limitations, respira-

tory compromise, reduced head and trunk control,

changes in muscle tone or challenging behaviours. Stan-

dards Australia (1996a,b) has produced a document,

Restraint of Children with Disabilities in Motor Vehicles(AS ⁄ NZS 4370), which provides voluntary guidelines for

therapists who prescribe car restraints for children with

additional needs to ensure that children are seated safely

and in accordance with legal requirements. Sometimes, to

seat children with additional needs safely, therapists are

required to make modifications to car restraints that

comply with Australian Standards AS ⁄ NZS 1754. More

frequently, therapists recommend the purchase of car

restraints that have been specifically designed for

children with additional needs. These restraints are all

imported from overseas, and have not been certified to

Australian Standards AS ⁄ NZS 1754.

Given the relationship between sub-optimal restraint

usage and injury outcome, it is imperative that therapists

are able to make informed and accurate recommendations

when prescribing car restraints for children with addi-

tional needs. The legal implications for both therapists

and families related to the restraint of children in motor

vehicles, means that therapists carry a large responsibility

when making these decisions. This research project aimed

to understand the knowledge of and challenges faced by

occupational therapists when making recommendations

regarding the restraint of children with additional needs

in motor vehicles in Victoria, Australia.

Methods

Study design

This research project used a cross-sectional survey

design.

Australian Occupatio

Participants

Participants were occupational therapists currently work-

ing in Victoria, Australia, with children aged from birth

to 18 years in early intervention services, hospitals,

schools, community services or private practice.

Data collection instrument

An online self-administered survey was designed specifi-

cally to address the aims of this research project. Prior to

data collection, the survey was piloted with three occu-

pational therapists currently working in paediatrics,

and two external stakeholders with expertise in child

safety and transport. Revisions were made according to

their feedback. The final survey was comprised of 25

closed response and one open response question, and

took approximately 15–20 minutes to complete. Closed

response questions were primarily used to reduce the

time it took to complete the survey and to reduce the

chance of incomplete responses. The survey was divided

into four sub-sections:

1. Demographic and employment information: This section

requested demographic information of participants,

including gender, years of practice, employment sector

and client age and diagnostic group.

2. Clinical issues – decision-making: This section focussed

on how often and the reasons why participants are asked

to make recommendations regarding the restraint of chil-

dren with additional needs in motor vehicles. This sec-

tion included a Likert scale to ascertain how confident

participants are when making such decisions. Barriers to

making suitable recommendations were also explored.

3. Clinical issues – service delivery: This section focussed

on participants’ access to and use of Standards Australia

AS ⁄ NZS 4370 Restraint of children with disabilities in motorvehicles. This section also required participants to identify

waiting times and funding bodies used when sourcing

appropriate equipment and restraints.

4. Additional information: This section enabled partici-

pants to identify information and resources that would

facilitate their ability to confidently make recommenda-

tions regarding the restraint of children with additional

needs in motor vehicles.

Procedure

This research project was approved by the Ethics Commit-

tee at the Royal Children’s Hospital (RCH), Melbourne,

Australia. An email containing an invitation to participate,

a plain language participant statement and a link to the

online survey was sent to paediatric occupational thera-

pists. Participants were recruited from two sources:

1. Paediatric Occupational Therapists in Victoria, Aus-

tralia, have access to a listserv (VicPOTS) that was set up

to share information about job vacancies, professional

development courses and research. All current VicPOTS

members received an email inviting them to participate

in the research project.

��C 2011 The Authorsnal Therapy Journal ��C 2011 Occupational Therapy Australia

TABLE 1: Diagnostic groups seen by participants

Diagnosis

Frequency

(n = 102) Percentage

Developmental delay 87 87.9

Autism 77 77.8

Cerebral palsy 65 65.7

ADHD 51 51.5

Acquired brain injury 34 34.1

Muscular dystrophy 31 31.3

Hand and upper limb conditions 29 29.3

Orthopaedic conditions

(including orthopaedic surgery)

29 29.3

Spinal conditions

(including spinal surgery)

27 27.3

Participants were asked to select all relevant choices.

The frequency is greater than 102; the percentage total is

greater than 100.

RESTRAINT OF CHILDREN WITH ADDITIONAL NEEDS 19

2. OT AUSTRALIA (Victoria) provides special interest

groups as a service of the organisation. Members can

elect to join the Paediatric Special Interest Group (PSIG)

and to receive email updates when they purchase their

membership. OT AUSTRALIA (Victoria) forwarded

information as outlined before to all members who had

indicated an interest in paediatrics.

It is also possible that some occupational therapists

who are not members of either VicPOTS or the PSIG

received the link to the survey via an email from a col-

league. This was not monitored or requested by the

researchers.

Consent to take part in the research project was

implied in the completion of the survey. Researchers did

not have access to the contact details of any participant,

and all surveys were completed anonymously. The sur-

vey remained open for four weeks. A reminder email

was sent out to both mailing lists one week prior to the

survey closing.

Data analysis

Data from each question were extracted, and analysed

using descriptive statistics to identify frequency distribu-

tions and measures of central tendency.

Results

Participants

As participants could be members of both VicPOTS and

the PSIG, the response rate cannot be accurately calcu-

lated. A total of 102 occupational therapists completed

the survey. Ninety-seven (95.1%) participants were

women, and five (4.9%) were men. The majority of partic-

ipants reported holding a bachelor degree (n = 85,

85.9%), and there was a relatively even distribution of

years of experience working in paediatrics. Twenty-

nine (28.4%) participants had been working for 0–2 years,

25 (24.5%) participants had been working for 3–5 years, 23

(22.5%) participants had been working for 16+ years and

the remainder of participants had been working for either

6–10 years or 11–15 years. The most frequently reported

area of practice was the community sector (n = 40,

40.4%), followed by not for profit services (n = 27, 27.3%)

and public hospitals (n = 20, 20.2%). Participants

reported working with a range of diagnostic groups

(see Table 1), including developmental delay, autism,

cerebral palsy, attention-deficit ⁄ hyperactivity disorder

and acquired brain injury (ABI), with the majority of par-

ticipants working with children aged 3–5 years (n = 60,

60.6%) followed by 6–12 years (n = 29, 29.3%), 0–2 years

(n = 6, 6.1%), 13–17 years (n = 2, 2.0%) and 18 years

(n = 2, 2.0%).

Clinical issues: Decision-making

Seventy-nine (95.2%) participants indicated that it is the

occupational therapist in their workplace who is primar-

��C 2011 The AuthorsAustralian Occupational Therapy Journal ��C 2011 Occupational Th

ily asked to make recommendations regarding the

restraint of children with additional needs in motor

vehicles, with very few doctors (n = 2, 2.4%) and physio-

therapists (n = 2, 2.4%) being asked to make these recom-

mendations. The majority of participants reported being

asked to make car seating recommendations once every

7+ months (n = 33, 39.8%), with fewer participants mak-

ing car seating recommendations on a weekly (n = 6,

7.2%) or monthly (n = 5, 6.0%) basis. When asked to

select all reasons that applied, participants reported being

asked to make car seating recommendations due to

behavioural challenges (n = 66, 79.5%), challenges with

seating posture due to increased ⁄ decreased muscle tone

(n = 59, 71.5%), orthopaedic limitations (n = 24, 28.9%),

challenges with seating due to other illness or medical

intervention (n = 21, 25.3%) and respiratory issues (n = 4,

4.8%).

Table 2 shows the challenges faced by therapists when

making recommendations regarding the restraint of chil-

dren with additional needs in motor vehicles, with inade-

quate funding being the greatest issue reported by

participants. As shown in Table 3, there was a high

degree of variability in participants’ knowledge of

standards-approved options, non-standards-approved

options and legal requirements for seating children with

additional needs. Eleven participants (11.5%) strongly

agreed that they were aware of the standards-approved

options currently available for seating children with

additional needs, 36 (37.5%) participants agreed, 19

(19.8%) participants responded neutrally, 25 (26.0%) par-

ticipants disagreed and 5 (5.2%) participants strongly

disagreed. In terms of non-standards-approved options

available, 9 (10.7%) participants strongly agreed that

they had good awareness of these options, 35 (41.7%)

erapy Australia

TABLE 2: Challenges faced by therapists when making recommendations regarding the restraint of children with additional needs in

motor vehicles

Challenges Frequency

(n = 102) Percentage

Inadequate funding for appropriate equipment 71 84.5

Large amount of time taken to make and implement recommendations 54 64.3

Lack of knowledge regarding legal requirements for prescription of car seats for children

with additional needs

51 60.7

Low demand for service, therefore limited opportunity to develop expertise 50 59.5

Lack of knowledge regarding commercially available car seating or restraint options 47 56

Pressure from other members of the allied health team 7 8.3

Participants were asked to select all relevant choices. The frequency is greater than 102; the percentage total is greater

than 100.

TABLE 3: Distribution of participants’ knowledge of standards-

approved options, non-standards-approved options and legal

requirements for seating children with additional needs

Standards-

approved

options

(n = 96)

Non-standards-

approved

options (n = 84)

Legal

requirements

(n = 96)

n (%) n (%) n (%)

Strongly

agree

11 (11.5) 9 (10.7) 11 (11.5)

Agree 36 (37.5) 35 (41.7) 39 (40.6)

Neutral 19 (19.8) 14 (16.7) 26 (27.1)

Disagree 25 (26.0) 20 (23.8) 16 (16.7)

Strongly

disagree

5 (5.2) 6 (7.1) 4 (4.2)

Some participants did not answer this question. The

frequency of responses is 96 for standards-approved

options and legal requirements, and 84 for non-standards-

approved options, rather than 102.

20 A. BAKER ET AL.

participants agreed, 14 (16.7%) participants responded

neutrally, 20 (23.8%) participants disagreed and 6 (7.1%)

strongly disagreed.

Ninety per cent of participants (n = 76) indicated that

having access to a written resource would be the best

way to increase their skills and confidence in recom-

mending car restraints for children with additional

needs. The majority of participants indicated that the best

place to access this resource would be electronically on

the OT AUSTRALIA (Victoria) website (n = 76, 93.8%).

When asked to select all that applied, participants indi-

cated that the resource should include: a summary of

AS ⁄ NZS 4370 Restraint of children with disabilities in motor

Australian Occupatio

vehicles (n = 79, 97.5%), a list of equipment providers

(n = 79, 97.5%), VicRoads legislation (n = 77, 95.1%) and

a list of key contacts (n = 72, 88.9%).

Clinical issues: Service delivery

The majority of participants (n = 50, 61%) did not have

access to a copy of AS ⁄ NZS 4370 Restraint of children withdisabilities in motor vehicles. Twenty-five (30.5%) partici-

pants were unaware that these documents existed, 18

(22.0%) participants indicated that they did not make car

seating recommendations often enough to warrant

purchase of the document and 10 (12.2%) participants

indicated that cost prevented them from accessing the

document.

In relation to purchasing equipment and restraints, the

majority of participants (n = 47, 57.3%) indicated that it

is the child’s family that pays for the recommended

equipment, with charities ⁄ non-government organisations

(n = 34, 41.5%) and the Transport Accident Commission

(TAC) who provide support for children injured in motor

vehicle accidents paying for equipment on a less frequent

basis (n = 1, 1.2%). Table 4 shows the average time that it

takes families to self-fund equipment after it has been

recommended by therapists.

Discussion

This research project aimed to understand the knowledge

of and challenges faced by occupational therapists when

making recommendations regarding the restraint of chil-

dren with additional needs in motor vehicles in Victoria,

Australia. No other studies have been identified that

investigate knowledge and practice in this area.

Therapists’ knowledge of Australianstandards and legal requirements

Although this research project has indicated that occupa-

tional therapists remain the member of the multi-disci-

plinary team who is most often asked to make car seating

��C 2011 The Authorsnal Therapy Journal ��C 2011 Occupational Therapy Australia

TABLE 4: Average time that it takes families to self-fund

equipment after it has been recommended by therapists

Time

Frequency

(n = 87) Percentage

One week or less 3 3.4

Up to 1 month 16 18.4

1–3 months 26 29.9

4–6 months 16 18.4

7+ months 4 4.6

Families do not purchase

the recommended equipment

and continue to transport

their child in a way that

I consider to be unsafe

22 25.3

Fifteen participants did not answer this question.

The frequency is 87, rather than 102.

RESTRAINT OF CHILDREN WITH ADDITIONAL NEEDS 21

recommendations, therapists are receiving referrals on a

relatively infrequent basis, with the majority of therapists

only required to make such recommendations once every

seven months or more. The inconsistency of referrals and

the limited opportunity to implement car seating knowl-

edge and skills makes it hard for therapists to maintain a

current working knowledge of relevant standards. The

Occupational Therapy Australia Code of Ethics (2001,

p. 5) states that ‘all members of the occupational therapy

profession have an individual responsibility to maintain

their own level of professional competence and each of

them must strive to improve and update knowledge and

skills’. Only half of the participants in this study

indicated that they had an appropriate knowledge of

standards-approved restraint options, non-standards-

approved options and legal requirements for seating

children with additional needs. Furthermore, the fact that

61% of therapists reported that they did not have access

to a copy of Standards Australia AS ⁄ NZS 4370 Restraintof children with disabilities in motor vehicles implies that

there are a number of therapists without an appropriate

knowledge of these standards. There are both legal and

ethical implications of this for therapists. Previous

research into the use of restraints for wheelchairs has

implicated therapists who have not followed appropriate

guidelines, and in at least one incidence in Australia a

child has died due to incorrect use of a postural harness

in a wheelchair (Australian Occupational Therapy News,

2002). The risks that arise from not following appropriate

standards when making car seating recommendations

are the same, and therapists who are making these rec-

ommendations need to be supported to develop and

maintain their knowledge in this area. This may include

opportunities to attend short courses, having access to

written guidelines or obtaining colleague opinion.

��C 2011 The AuthorsAustralian Occupational Therapy Journal ��C 2011 Occupational Th

Issues seating children with behaviouraldifficulties

Although there is a large body of information available in

Restraint of children with disabilities in motor vehicles(AS ⁄ NZS 4370) related to seating children with physical

difficulties, there is less information available to assist

therapists with clinical reasoning and problem-solving

restraint options for children who present with behavio-

ural challenges. Participants in this study reported being

asked to make car seating recommendations for children

with behavioural issues and challenges more often than

for children with physical difficulties. Huang et al. (2009)

identified a number of issues associated with car travel

for children who have behavioural difficulties. These

issues related to the child’s limited understanding of

safety rules, difficulties inhibiting impulses, inability to

follow directions and the need for the driver to provide

constant monitoring of the child throughout the car trip.

Given that there are a large number of occupational ther-

apists dealing with children who have behavioural diffi-

culties, there is a clear need for further research and

strategies to assist therapists to make appropriate recom-

mendations for this client group. Directions for further

research may include team responses and behavioural

management plans which develop skills in preparing

children for car travel. This is an area where no guide-

lines currently exist.

Families’ inability to purchase equipmentand restraints

Serious injury has been associated with the use of

restraints by children outside the age, weight and height

range for which they were designed, with children who

are sub-optimally restrained at the time of a crash receiv-

ing a greater proportion of moderate to severe injuries

than those who are optimally restrained (Brown et al.,2006). In line with the study completed by Brown et al.,participants in this research project indicated that in a

quarter of cases families do not purchase the restraints

recommended by therapists, and continue to transport

their child in a way that is considered to be unsafe. This

may primarily be due to the high cost of equipment and

restraints, with families being the primary source of

funding for specialised car restraint options recom-

mended by therapists. Socioeconomic status (SES)

has been found to have a direct correlation with safety

behaviours and restraint usage, with families of low SES

displaying a high frequency of non-compliance (Korn,

Katz-Leurer, Meyer & Gofin, 2007). Given that motor

vehicle crashes remain one of the leading causes of injury

and death among infants and children in Australia

(Australian Bureau of Statistics, 2010), this raises con-

cerns for families who are unable to fund the necessary

equipment that is required to transport their child safely.

For those families who do purchase the equipment and

restraints recommended by therapists, on average it takes

erapy Australia

22 A. BAKER ET AL.

between one and three months for families to be able to

self-fund the purchase. Children with additional needs

are required to travel on a frequent basis, especially to

access medical appointments. For these children, public

transport is often not a viable option secondary to physi-

cal, cognitive or behavioural difficulties. This poses a sig-

nificant restriction on families’ ability to engage in

occupations outside the home, and raises issues for fami-

lies about how to safely transport their child while they

are waiting for funding of the equipment required for

safe car travel.

Directions for future research

The results of this research project have highlighted the

need for the development of additional resources for

therapists to use when making recommendations regard-

ing the restraint of children with additional needs in

motor vehicles. Participants have indicated that having

electronic access to a written resource would be the best

way to increase their skills and confidence in making rec-

ommendations. Specific information to include in this

resource may relate to Standards Australia AS ⁄ NZS 4370

Restraint of children with disabilities in motor vehicles, strate-

gies for seating children with behavioural difficulties,

and alternative funding options for those families that are

unable to fund the recommended equipment and

restraints. Ongoing research is also required to look at

the high cost of equipment and restraints which are all

imported from overseas, and the impact that this is

having on families of children with additional needs.

Limitations

Road rules and funding of specialised car restraints vary

between each state in Australia. As a result, the outcomes

of this research project can be generalised only to occupa-

tional therapists currently working in Victoria, Australia.

Although there was a strong response to the online sur-

vey, the response rate cannot be accurately calculated. It

is likely that there was some overlap between the mailing

lists of VicPOTs and of the PSIG, but it is also likely that

there are therapists who are members of only one list. To

maintain confidentiality, no attempt was made to deter-

mine the overlap between the two groups. Furthermore,

it is not clear if all participants are currently working in

Victoria, as it is possible that some participants may have

received the survey link via email from a colleague.

Conclusion

Children need to be able to travel safely and comfortably

in a car to enable them to be transported to and from

school, to and from leisure activities and to and from

medical appointments. As part of their role in facilitating

occupational performance, occupational therapists are

involved in making recommendations regarding the

restraint of children with additional needs in motor vehi-

cles. Given the relationship between sub-optimal restraint

Australian Occupatio

usage and injury outcome, it is imperative that therapists

are able to make accurate recommendations. Further

work is required to develop appropriate resources which

support therapists to make such recommendations. This

project provides baseline data describing the current

practice of occupational therapists involved in making

car seating recommendations for children with additional

needs in Victoria, Australia. This information can be used

to evaluate the impact of new educational materials and

to enable comparison of changes in clinical practice over

time.

Acknowledgements

This research project was supported by funding from OT

AUSTRALIA – Victoria. This project was supported by

the Victorian Government’s Operational Infrastructure

Support Program.

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��C 2011 The Authorsnal Therapy Journal ��C 2011 Occupational Therapy Australia