Improving Omar's safety and postural support in the car
How both short and long term solutions helped Omar
This case study features in 'Postural support' and 'Children who get out of their restraints.'
Omar is 4 years and 2 months of age. Omar has diagnoses of Global Developmental Delay, Autism Spectrum Disorder with associated cognitive delay, extreme emotional and behavioural challenges, delayed receptive and expressive communication. In addition he is undergoing investigation for an endocrinological disorder at the Royal Children’s Hospital. This condition may attribute to Omar being extremely tall and heavy for his age (he currently weighs 50 kg and is 114 cm tall).
Omar lives in Victoria, with his mother.
Step 1: Assess
Omar can walk short distances but due to his extremely low muscle tone and strength, body size and poor foot and leg posture issues, he often trips and stumbles. His endurance is very limited (he can walk approximately 50 metres before fatiguing).
Omar has reduced postural tone and in a sitting position he fatigues after 5-10 minutes, becoming asymmetrical with poor neck and head position.
Omar lives with his mother, Sameer, who has limited family support and experiences physical and mental health issues that makes caring for Omar extremely difficult. She experiences a high level of carer burden, stress, and exhaustion in her caring role. Sameer has chronic back pain, caused by, and exacerbated by constantly lifting Omar. As a single mum, Sameer provides full support for Omar outside of his childcare hours.
The family car is a Holden Commodore 2010 (no ISOFIX points). Omar currently travels in a forward-facing Australian standard car seat with built-in harness; however, he has outgrown this car seat, and it no longer provides him with adequate postural support.
In addition, Omar often gets out of the car seat and moves around the vehicle during travel. On many occasions, Sameer has needed to urgently pull off the road to re-secure Omar in his car seat.
Behavioural and distraction strategies to encourage Omar to remain in the car seat (e.g., using iPad and toys, simple instructions, positive praise, and rewards from Sameer) have had minimal effect.
Lauren, Omar’s OT, has identified Omar’s need as very urgent as Omar does not have adequate postural support and is at extreme risk (to himself and others) when he gets out of his car seat and moves around the vehicle.
Step 2: Plan
Step 1 helped Lauren to define criteria for vehicle restraint option selection: Omar required a large car seat to cater for his size and weight; a built-in harness for postural support and anti-escape features.
Guided by AS/NZS 4370, Lauren scanned the market, investigating the feasibility of Australian standard car seats first. Lauren arranged a visit to the local Baby Bunting with Omar and Sameer to trial several new Australian standard car seats. However, all car seats trialed were either inadequate in terms of their size, postural support they provided to Omar, or safety (harness buckles which Omar could open).
Lauren then considered modifying his current car seat by using a child restraint buckle cover. However, this would only (potentially) prevent Omar getting out of his car seat – it did not address his postural support needs and that fact that the car seat was too small for him.
Lauren then considered the option of a special purpose car seat. After online research and discussion with specialist equipment suppliers, regarding Omar’s size, support and safety requirements, a trial of an extra large special purpose car seat was arranged at the family home. The trial was successful with Omar being well supported in a slightly reclined position in this car seat with the shoulder, harness and head supports. It is anticipated that this car seat will accommodate his growth for some years. The harness buckle with pen popper buckle means that Omar is unable to get out of his car seat.
A behaviour support plan was co-developed by a team psychologist and Sameer, and this was immediately implemented with Omar. The plan included parent coaching with the aim of helping Sameer to understand Omar’s behaviour and its purpose, to issue simple and consistent instructions and to provide positive behavioural support.
The behaviour plan was implemented immediately, and Lauren prescribed a child restraint buckle cover for short term use (while waiting for his new special purpose car seat) to mitigate the immediate risk of Omar continuing to get out of his car seat.
At times, the behavioural strategies were successful, but when Omar became unsettled or overstimulated, he was able to get the short-term option of the harness buckle cover off, unbuckle himself from his car seat and move around the car. In these situations, Lauren identified two options – 1) Sameer does not take Omar in the car if he is behaviorally unsettled and she cannot calm him 2) where possible an additional adult travel in the car. As Sameer is a single parent with limited support, Lauren advised use of a carer under the NDIS funding.
Step 3: Implement
Lauren completes the Advice to Parent form to prescribe the child restraint buckle cover (short term use) and the extra large special purpose car seat. She states that Omar’s travel arrangement will be reviewed every 3 months in line with the restrictive practices review.
In the section on the Advice to Parent form about installing, using, and maintaining the car seat, Lauren states that the special purpose car seat must be always used with the vehicle seatbelt when travelling (the harness only provides postural support).
Lauren completes a referral letter for Sameer to obtain a medical certificate from Omar's doctor. This is required for both the use of the short term solution of the child restraint buckle cover and the longer term solution of the special purpose car seat. This will allow Omar to legally use the buckle cover and travel in the car seat, whilst awaiting the arrival of the special purpose car seat. Lauren instructs Sameer to ensure the medical certificate is always in the vehicle when Omar is travelling.
Lauren completes the NDIS AT form (to apply for funding for the extra large special purpose car restraint). As the special purpose car seat had the feature of the pen popper buckle guard, Lauren includes a notification for Restrictive Practice to the NDIS Quality and Safeguards Commission. As part of the notification for Restrictive Practice, Lauren develops, implements, and submits a Risk Assessment and Behaviour Support Plan. She includes a copy of the Advice to Parent form with the application. *** Helen – here we need to confirm the info on what you have to do to maintain the restrictive practice report- I think it is monthly updates, and also we need to check in with the state rules also)
When the extra large special purpose car seat arrives, Lauren organises the specialist equipment supplier to assist with instalment. Lauren ensures that the car seat is adjusted to fit Omar and again instructs Sameer to always use the vehicle seatbelt with the special purpose child restraint.
Lauren and Sameer confirm the behavior management and additional parent support strategies.
Step 4: Review
Lauren schedules a review at 3 months, 6 months, and 12 months.
At the review meetings, Lauren and Sameer review Omar’s behaviour support plan and strategies with the aim of removing the pen popper harness buckle when Omar can consistently remain in his car seat. At the 12-month review, Lauren and Sameer determined that the pen popper feature was still required, and updated the NDIS Restrictive Practice notification.
I’m so happy Omar is safe in his car seat and he can’t get out and move around in the car when I am driving on the freeway like he has done before. When he is tired and asleep, he looks comfortable.